This information summarizes what adenomyosis is, the main signs and symptoms and current ways of managing it. It is intended for those who may have adenomyosis.
What is it?
Adenomyosis is defined by the finding of endometrium (the tissue that normally lines the inside of the uterus/womb) within the myometrium (muscular wall of the womb). The cause is not known, although there are several theories. One theory is that it has a hormonal origin, another is that it may be due to disruption of the myometrium. Adenomyosis can be found in women of all ages, including adolescents. It is often found in women with endometriosis.
What symptoms are associated with adenomyosis?
Women with adenomyosis often have particularly painful and/or heavy periods (Pepas, L. et al, 2012). However, women with adenomyosis may have no symptoms.
How is it diagnosed?
Adenomyosis can be difficult to diagnose but increasingly pelvic ultrasound and MRI are being used. With transvaginal ultrasound, considerable training is needed to recognize the ultrasound pattern in the diagnosis of adenomyosis. With MRI, the findings are less dependent on the person doing the scan, but requires an observer who is expert in reporting (Dueholm 2007). Adenomyosis can be easily confused with fibroids on both ultrasound and MRI. You may want to ask to be referred to someone who is experienced in recognizing and identifying adenomyosis in imaging/radiology. Adenomyosis may be a reason for continuing pain following surgery for endometriosis.
How is it treated?
Surgery (hysterectomy) has been the conventional treatment for adenomyosis for many years. However, increasingly a medical approach is being used.
Medical treatment for adenomyosis-associated pain includes anti-inflammatory medications and hormone therapy such as the combined pill, progestogens ( oral ands intramuscular ), agonists (e.g. Zoladex and Decapetyl) or levonorgestrel-releasing intrauterine devices (LNG-IUD e.g. Mirena).
A study investigating the long term effects of a LNG_IUD concluded that it helped with relief of symptoms for up to two years, after which time efficacy decreased ( CHO 2008).
Uterine Artery Embolisation (UAE) may be an option. However, the National Institute of Health and Care Excellence (NICE) encourages further research into the effects of UAE compared with other procedures to treat adenomyosis, particularly for those wishing to maintain or improve their fertility (NICE IPG 473). UAE involves injecting small particles into the blood vessels that take blood to the uterus, via arteries in the groin. The aim is to block the blood supply to the adenomyosis so that it shrinks, which may then relieve the symptoms. During the consent process, patients should be informed that symptoms may not be relieved, that symptoms may return and that further procedures may be needed. Patients contemplating pregnancy should be informed that the effects of the procedure on fertility are uncertain.
In the last few years, there have been several studies using high intensity focused ultrasound (HIFU) ablation therapy for adenomyosis, with up to two years follow-up. All of the studies conclude that this therapy may be a safe and effective non-invasive alternative to treat adenomyosis (Wang 2009, Zhou 2011, Zhang 2013). The study by Wang suggested that the severity of symptoms correlates with the extent of adenomyosis, and that ablating sufficient volume of adenomyosis may provide greater pain relief
Magnetic resonance imaging-guided focused ultrasound (MRgFUS) has been used in a few small studies for those with focal adenomyosis. These studies suggest that clinical improvement in symptomatic adenomyosis is achievable within a short period of time after treatment with MRgFUS. MRgFUS is a non-invasive, day-care procedure, requiring no admission, and having a low complication rate (Kim 2011, Fan 2012 ). MRgFUS may be a promising alternative to hysterectomy for the patient with adenomyosis who wishes to preserve her uterus. A number of reports of successful treatment have been published that also show the feasibility of pregnancy following MRgFUS (Rabinovici 2010).
To our knowledge HIFU and MRgFUS are not performed for adenomyosis in the UK, although the latter is carried out in some cases for women with fibroids.
There have been a few non-randomized studies of conservative surgery, termed ‘adenomyomectomy’ (excision of the adenomyosis) suggesting that this may relieve symptoms while conserving the uterus (Takeuchi 2006, Sun 2011). One study (Wang 2009 ) concluded that surgical and medical treatment (GnRH agonist ) combined gave a lower symptom-relapse rate than surgery alone during the two year follow up period. Adenomyomectomy is an advanced surgical procedure and in our opinion patients considering such a procedure should ask about the experience and outcomes of the surgeon (Pepas 2012). There may be a role for hysteroscopic endometrial resection or ablation if the adenomyosis is superficial, involving less than 3 mm of the myometrium.
In our opinion greater accuracy in diagnosis of adenomyosis and increased efforts to offer alternatives to hysterectomy would be welcome.Information about alternatives should be available to patients before, during and after consultations, to assist in decision making.
References and further reading
Champaneria, R., Abedin. P., Daniels, J., Balogun, M., Khan, K.S. Ultrasound scan and magnetic resonance imaging for the diagnosis of adenomyosis: systematic review comparing test accuracy. Acta Obstetricia et Gynecologica Scandinavica 2010
Cho S. Nam A. Kim H. Chay D. Park K. Cho DJ. Park Y. Lee B Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis . American Journal of Obstetrics & Gynecology. 198(4):373.e1-7, 2008
Pepas, L., Deguara. C, Davis, C, Update on the surgical management of adenomyosis.Curr Opin Obstet Gynecol.August 2012